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The modified tunnel technique – options and indications for mucogingival

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JPI0112_P000_000_ART_A 7/03/12 9:39 Page 1
The modified tunnel
technique – options
and indications
for mucogingival therapy
Technique de tunnélisation
modifiée : options
et indications en chirurgie
muco-gingivale
ABSTRACT
Different methods for coverage of gingival recessions and
soft tissue augmentations using pedicle flaps and/or connec-
tive tissue grafts (CTG) have been reported. One of the inno-
vative techniques to increase the amount of keratinized tis-
sue is the modified tunnel technique which is designed as
split flap without vertical releasing incisions. In contrast to
the original technique, the modification combines the inser-
tion of a CTG with coronal advancement of the tunnel com-
plex. The present article describes the main characteristics
and highlights different indications and limitations for this
technique. Depending on recession depth and the presence
of keratinized tissue an indication guideline for decision
making is introduced.
KEY WORDS
Mucogingival surgery, recessions, modified tunnel technique.
Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1
> OS X Couleur
Jamal M. STEIN1, 2
Christian HAMMÄCHER2
1- Department of Operative Dentistry,
Periodontology and Preventive Dentistry,
University Hospital Aachen, Aachen,
Germany
2- Clinic for Implantology, Periodontology
and Prosthodontics, Aachen, Germany
Accepted for publication:
15 september 2011
The authors report no conflicts of
interest relevant to this publication.
RÉSUMÉ
Différentes techniques ont été décrites pour recouvrir les
récessions gingivales et augmenter les tissus mous : lam-
beaux pédiculés et/ou greffes de tissu conjonctif. Parmi les
techniques novatrices visant à augmenter la quantité de tissu
kératinisé, on trouve la celle de tunnélisation modifiée qui
se définit comme étant un lambeau d’épaisseur partielle réa-
lisé sans incisions de décharge. Contrairement à la technique
d’origine, cette modification associe l’insertion d’une greffe
de tissu conjonctif avec un repositionnement plus coronaire
de l’ensemble de la zone tunnélisée. Cet article décrit les
principales caractéristiques et met l’accent sur les différentes
indications et limites que présente cette technique. Un guide
des indications en fonction de la profondeur de la récession
et la présence ou non de tissu kératinisé est présenté pour
aider le clinicien dans sa prise de décision.
MOTS CLÉS
Chirurgie muco-gingivale, récessions, technique de tunnéli-
sation modifiée.

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The modified tunnel technique – options and indications for mucogingival therapy
Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale
Introduction
Gingival recessions are defined as
exposure of the root due to an api-
cal movement of the margo gingi-
vae. Their prevalence seems to in-
crease from 8% in children to 100%
in adults with an age of 50 years and
more (Kassab and Cohen 2003;
Woofter, 1969). Etiologic factors
comprise primary morphogenetic
and secondary factors. Primary mor-
phogenetic factors are the absence
or dehiscence of buccal bone wall
(Lost, 1984) and/or a thin gingival
biotype (Müller et al., 2000), while
traumatic brushing (Serino et al.,
1994), inflammatory periodontal di-
sease (Wennström, 1996) or ortho-
dontic movement of teeth (Coatoam
et al., 1981) are secondary factors.
Plastic periodontal surgery offers se-
veral options to tr eat and pr event
periodontal recessions. According
to the suggestions of Miller (Miller ,
1985) and Harris (Harris, 1994), the
aims of surgical coverage of perio-
dontal recessions are the establish-
ment of a complete r oot coverage
with a minimum of keratinized (at
least 2 mm width), healthy perio-
dontal tissue (pr obing depth < 3
mm, no bleeding of probing) and an
esthetical result and physiologic form
of the gingiva. The meaning of tis-
sue thickness for stabilization of
treatment results, e.g. the goal to
turn a thin into a thick biotype, has
already been emphasised in earlier
studies (Wennström, 1990).
Many surgical techniques have been
proposed to achieve root coverage.
Systematic reviews with meta-ana-
lyses (Roccuzzo et al., 2002; Oates
et al., 2003; Cairo et al., 2008) de-
monstrated that for coverage of lo-
calized Miller class I and II r eces-
Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1
sions cor onally advanced flaps
(CAF), connective tissue grafts (CTG)
and guided tissue regeneration (GTR)
can be used, however the amount
of root coverage with CTG was sta-
tistically superior to GTR (Roccuz-
zo et al., 2002; Oates et al., 2003).
Further, the combination of CAF with
CTG showed a sign ificantly better
percentage of coverage than CAF
alone (Cairo et al., 2008). Similar, the
use of biologic factors such as en-
amel matrix derivatives (EMD) in ad-
dition to the CAF significantly en-
hanced the clinical outcomes
compared to CAF alone. Although
root coverage after CAF + CTG and
CAF + EMD did not significantly dif-
fer from each other (Cair o et al.,
2008), the amount of keratinized tis-
sue was higher after the use of CAF
+ CTG compared to CAF + EMD
(McGuire and Nunn, 2003).
For treatment of multiple recessions
and those with Miller class III only
limited data are available. In the last
decades, coronally advanced flaps
(Zucchelli and DeSanctis, 2000),
connective tissue grafts using the
“envelope” technique with prepara-
tion of a supraperiosteal mucosa flap
(Raetzke, 1985) and its extension
over more than one recession in form
of a tunnelling pr ocedure (Allen,
1994) were the base of modifica-
tions and new flap designs to treat
multiple recessions. In order to use
an incision-free technique to cover
recessions with optimal aesthetic
appearance, the tunnel technique
has been further developed and mo-
dified (Azzi and Etienne, 1998; Za-
balegui et al., 1999). In the present
article, indications, options and li-
mitations for this technique will be
reported.
> OS X Couleur
The modified
tunnel technique
According to the protocol of Allen
(Allen, 1994), the design for the ori-
ginal tunnel technique comprises the
preparation of a supraperiosteal mu-
cosa flap with intrasulcular incisions.
This allows the mobilisation of the
cervical gingiva and, ther efore, the
creation of a “pouch”. By undermi-
ning the inter dental papillae a mu-
cogingival tunnel between all adja-
cent pouches can be developed.
The subepithelial CTG is then inser-
ted into the tunnel, partly exposed
over the recessions and sutured in
this position. Since the amount of
root coverage is depending on the
size of the graft which survives over
the root surface, necrosis of the ex-
posed parts of the CTG is one of the
problems which limit the pr edicta-
bility of this original technique. T o
overcome this problem, a better co-
verage of the CTG should be achie-
ved. Therefore, it has been sugges-
ted to coronally advance the pouch
and the tunnel. This modification has
been described by Azzi and Etien-
ne (Azzi and Etienne, 1998). It re-
quires a mucoperiostal dissection
beyond the mucogingival junction
and under each papilla. Another mo-
dification is the application of a mi-
crosurgical approach using micr o-
surgical blades and sutures, which
minimizes the surgival trauma (Zuhr
et al., 2007; Cortellini andT onetti,
2001). New tunnel instruments (e.g.
Tunneling Knife I/II, Hu-Friedy, Rot-
terdam) which ar e small, specially
curved elevators have been deve-
loped in order to facilitate the supra-
periosteal preparation of the tunnel
and minimize the risk for iatrogenic
perforations. The main dif ferences

JPI0112_P000_000_ART_A 7/03/12 9:39 Page 3
regarding indication and flap desi-
gn between the envelope technique,
the original tunnel technique and the
modified tunnel technique are pre-
sented in table 1. Figure 1 shows
an example of a modified tunnel
technique in a patient with multiple
Miller class III recessions.
Advantages
and efficacy
of the modified
tunnel technique
Although CAF in combination with
CTG has been considered as stan-
dard for coverage of recessions for
a long time, the tunnel technique has
been further developed because it
offers several advantages. Since ver-
tical releasing incisions can be avoi-
ded, it is possible to pr eserve the
continuity of gingival papillae and
optimize the blood supply of the flap.
Thereby, interproximal tissue sup-
port is pr ovided by the underlying
CTG. Further, gain of keratinized tis-
sue and thickening of the gingiva
can be achieved with this technique.
Indication
Horizontal extension
of the mucosal flap
Mobilization
of the adjacent papillae
Coronal advancement
of the mucosal flap
The table shows the main differences between envelope technique (Raetzke et al., 1985), the original tunnel technique (Allen, 1994) and the modidied
tunnel technique (Azzi and Étienne, 1998) regarding to indication and flap design.
Table 1. Differences between envelope, original tunnel and modified tunnel techniques.
Tableau 1. Différences entre les techniques de l’enveloppe, de tunnélisation d’origine et de tunnélisation modifiée.
Both factors ar e important for the
establishment of stable periodontal
and/or peri-implant tissue.
To date, there are only three studies
published reporting results after root
coverage using the tunnel technique.
Aroca et al. treated 20 patients with
multiple Miller class III r ecessions
in a randomized contr olled split
mouth study (Ar oca et al., 2010).
They used a modified tunnel ap-
proach to insert a CTG with and wi-
thout enamel matrix derivates (EMD).
The authors demonstrate that the
modified tunnel technique with CTG
is a pr edictable method for Miller
class III recessions. The additional
application of EMD, however, did
not enhance the clinical outcomes.
The percentage of r oot coverage
was 82% (CTG + EMD) and 83%
(CTG), respectively. In another stu-
dy on five patients with multiple re-
cessions of Miller class I and II (Mo-
daressi and Wang, 2009), acellular
dermal matrix has been used ins-
tead of CTG for the tunnelling ap-
proach. In average, 61% o r ot cove-
rage and 0.15% increase of tissue
thickness could be ach ieved. In a
Original tunnel technique
Envelope technique
modifiée
Singular recessions Multiple recessions
One tooth Multiple adjacent teeth
No No
No No
Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1
> OS X Couleur
J. M. STEIN, C. HAMMÄCHER
recent study (Thalmair et al., 2011),
the amount of r oot coverage after
treatment of eight patients with mul-
tiple Miller class I recessions using
the modified tunnel technique was
examined. The authors r eport a
mean coverage rate of 93.3% after
six months. If the initial r ecession
depth was < 4 mm, complete co-
verage was found in 84%, in cases
with initial r ecession depths of ≥
4 mm, only 44% could be comple-
tely covered.
In summary, limited data point to a
high efficacy of the modified tunnel
technique using CTG, in particular
for recessions with moderate depths
(< 4 mm). Further studies with a hi-
gher statistical power should be per-
formed to verify the efficacy of this
technique.
Treatment options
for the modified
tunnel technique
Unfortunately, an indication scheme
for the modified tunnel technique
has not been reported in the litera-
Modified tunnel technique
Single or multiple
adjacent recessions
Multiple adjacent teeth
Yes
Yes
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The modified tunnel technique – options and indications for mucogingival therapy
Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

1a 1b

1c 1d

1e 1f

Fig. 1. Modified tunnel technique for coverage of multiple Miller class III recessions. a. Pre-operative view. b. Intrasulcular incision and preparation of
a supraperiosteal mucosa flap. c. Coronal advancement of the tunnel flap. d. Insertion of the CTG. e. Fixation of the CTG using external vertical mat-
tress sutures. f. Healing result 3 months post-operative.
Fig. 1. La technique de tunnélisation modifiée pour le recouvrement de récessions multiples de classe III de Miller. a. Vue préopératoire. b. Incision intra-
sulculaire et préparation d’un lambeau muqueux supra-périosté. c. Déplacement en direction coronaire du lambeau tunnélisé. d. Insertion de la greffe
de tissu conjonctif. e. Fixation de la greffe de tissu conjonctif à l’aide de sutures au point de matelassier verticales externes. f. Résultat de la cicatrisa-
tion à 3 mois postopératoires.

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J. M. STEIN, C. HAMMÄCHER

ture by now. However, there are dif- coronally advanced flaps (with CTG Coverage
ferent treatment options that can be or EMD) seem to be a better alter- of singular recessions
recommended. native (fig. 2). In patients with mul-
tiple Miller class II, the modified tun- Raetzke described the envelope
Coverage nel technique can be a very efficient technique in order to cover singu-
of multiple recessions method since tunnel preparation api- lar recessions using a CTG which
cally to the recession doesn’t requi- was sutured or sticked in a supra-
According to the original idea of the re mobilisation of attached gingiva periosteal “envelope”, prepared as
tunnel technique, this method can (fig. 3). In these cases the tunnel recession s urrounding m ucosal
be recommended for coverage of covering tissue mainly consists of flap without vertical r eleasing in-
multiple recessions with Miller class alveolar mucosa which makes mo- cisions (Raetzke, 1985). One of the
I, II or III if the recession depths are bilisation and coronal advancement disadvantages of this technique
moderate (< 4 mm). From a practi- of the tunnel easier (less tissue ten- was the fact that a high amount of
cal point of view, it should be noted sion). Also for Miller class III reces- the CTG was uncovered and pre-
that the difficulty of supracrestal pre- sions the tunnel technique provides dictability of root coverage was li-
paration beyond the mucogingival good results (Aroca et al., 2010). In mited due to the risk of (partial)
junction increases with the width of contrast to Miller class I, dissection necrosis of the (often) wide expo-
attached gingiva apically to the re- of the interdental papillae for coro- sed CTG. By undermining the ad-
cession. For multiple Miller class I nal advancement of the tunnel com- jacent papillae, the modified tun-
recessions with wide attached gin- plex even seems to be facilitated in nel technique enables cor onal
giva beyond the recession (≥ 3 mm), Miller class III (fig. 1). advancement of the tunnel.

2a 2b

2c 2d

Fig. 2. Example for an indication of a coronally advanced flap. a. Multiple Miller class I recessions with ≥ 3 mm width of keratinized tissue apical to the
recessions. b. Incision design (according to Zucchelli and De Sanctis, 2000). c. Post-operative view. d. Healing results 3 months post-operative.
Fig. 2. Exemple d’une indication de lambeau déplacé coronairement. a. Récessions multiples de classe I de Miller avec ≥ 3 mm de largeur de tissu kéra-
tinisé situé apicalement aux récessions. b. Tracé d’incision (d’après Zucchelli et De Sanctis, 2000). c. Vue postopératoire. d. Résultats de la cicatrisation
à 3 mois postopératoires.

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The modified tunnel technique – options and indications for mucogingival therapy
Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

Therefore, a higher amount of the
CTG can be covered (fig. 4).
Similar to the multiple r ecessions,
the modified tunnel technique is not
a suitable method if the amount of
attached gingiva apically to the re-
cession is ≥ 3 mm (alternative: CAF
+ EMD/CTG) or if the depth of the
recession is ≥ 4 mm (alternative: la-
teral sliding flap +EMD/CTG (fig. 5)
or free gingival graft).
Figure 6 shows a decision guideli-
ne for the indication of the modified
tunnel technique in or der to cover
gingival recessions.
Gingival thickening
(“biotype switching”)
Orthodontic movement of teeth
might lead to iatrogenic exposure of
roots, in particular in patients with
thin gingival biotypes (W ennström,
1996). In those patients gingival aug-
mentation (“biotype switching”) prior
to the orthodontic treatment can pre-
vent development of r ecessions
(fig. 7). Also restoration of teeth with
crowns with subgingival margin in
esthetically relevant regions and thin
gingival biotype might benefit from
a preceding thickening of the gingi-
va in order to avoid gingival tissue
loss after crown insertion (Borghet-
ti et al., 1990).
Peri-implant soft tissue
augmentation
Treatment on gingival r ecessions
(dehiscence defects) on implants is
still a challenge in mucogingival sur-
gery. In order to remain or augment
peri-implant tissue, we cr eated a
treatment strategy for tissue condi-
tioning prior, during or after implant

3a 3b

Fig. 3. Coverage of two adjacent Miller class II recessions using the modi-
fied tunnel technique. a. Pre-operative view. b. Post-operative view. c. Hea-
ling result 4 months post-operative.
Fig. 3. Recouvrement de 2 récessions adjacentes de classe II de Miller avec
la technique de tunnélisation modifiée. a. Vue préopératoire. b. Vue post-
3c opératoire. c. Résultat de la cicatrisation à 4 mois postopératoires.

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J. M. STEIN, C. HAMMÄCHER

4a

4b

Fig. 4. Coverage of a singular Miller class II recession using the modified

tunnel technique. a. Preoperative view. b. Post-operative view. c. Seven
days post-operative (after suture removal).
Fig. 4. Recouvrement d’une récession unitaire de classe II de Miller avec
la technique de tunnélisation modifiée. a. Vue préopératoire. b. Vue post-
4c opératoire. c. Sept jours postopératoires (après la dépose des sutures).

insertion using the modified tunnel
technique.
In patients wher e teeth with gingi-
val recessions or thin gingival bio-
types are planned to be replaced by
immediate implants, we aim to co-
ver the recessions and/or increase
the gingiva thickness on the tooth
three months prior to extraction and
implant insertion. Since blood sup-
ply for the CTG on the tooth is pro-
vided by blood vessels from perio-
dontal plexus, supraperiosteal plexus
and the covering flap (Guiha et al.,
2001), on implants nutrition for a
CTG is given by a comparably com-
promised periostal nutrition and the
overlapping flap only. Therefore, root
coverage with CTG will lead to a
more stable gingival augmentation
than on implants and should be
considered whenever a tooth with a
gingival deficit should be r eplaced
by an (immediate) implant (fig. 8).
Also during the insertion of an im-
plant a CTG might help to impr ove
the quantity and quality of peri-im-
plant tissue. Alternatively or additio-
nally, gingival augmentation can be
performed after implant insertion, in
particular during implant exposure.
Thereby, the modified tunnel tech-
nique represents an elegant method
to insert the CTG by careful lifting of
the papillae adjacent to the implant
(fig. 9).
Limitations
and conclusion
The modified tunnel technique is an
incision-free, minimally invasive me-
thod for gingival augmentation as
blood supply can be maximally pre-
served and coverage of the graft is
optimised compared to former tech-
niques. However, there are limita-
tions and contraindications which
should be considered.

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The modified tunnel technique – options and indications for mucogingival therapy
Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

5a

5b

Fig. 5. Example for an indication of a lateral sliding flap. a. Pre-operative

view. Recession depth ≥4 mm. Absence of keratinized tissue apical to the
recession. b. Incision design. c. Healing result after 3 months.
Fig. 5. Exemple d’indication de lambeau de translation latérale. a. Vue
préopératoire ; profondeur de la récession ≥4 mm ; absence de tissu kéra-
tinisé dans la zone apicale à la récession. b. Tracé d’incision. c. Résultat de
la cicatrisation à 3 mois.

Fig. 6. Indication scheme for the treatment of recessions of Miller class I,

II and III dependent on the presence of keratinized tissue apically and late-
rally to the recession defect, recession depth and gingival biotype. The
modified tunnel technique can be recommended in cases with limited
attached gingiva apically (< 3 mm) and recession depths of not more than
4 mm in Miller class I, II and III. Alternatively and in cases with recession
5c depths of ≥4 mm, lateral sliding flaps can be considered if sufficient late-
ral keratinized tissue is present. In patients with lack of apical and lateral
keratinized tissue, free gingival grafts may be
applicable.
Recessions KT: keratinized tissue; CAF: coronally advanced
Miller’s class I, II, III flap; EMD: enamel matrix derivates; CTG:
connective tissue graft.
Fig. 6. Protocole d’indication pour le traitement
Miller’s class I Miller’s class I, II, III de récessions de classes I, II et III de Miller selon
la présence de tissu kératinisé dans la zone api-
KT apical ≥ 3 mm KT apical < 3 mm cale et latérale de la récession, la profondeur de
la récession et le biotype gingival. La technique
THICK biotype THIN biotype Recession depth de tunnélisation modifiée peut être recomman-
Recession depth dée pour les cas de gencive attachée limitée dans
< 4 mm ≥ 4 mm la zone apicale (< 3 mm) et des profondeurs de
récession n’excédant pas 4 mm dans des classes
I, II et III de Miller.
CAF + EMD CAF + CTG YES En solution de remplacement, et pour les cas de
KT lateral récession dont la profondeur est ≥ 4 mm, les
lambeaux de translation latérale peuvent être
NO envisagés si l’on dispose d’une quantité de tissu
Lateral sliding flap kératinisé suffisante. Chez les patients présen-
tant un manque de tissu kératinisé dans les zones
(+ EMD/CTG) Free gingival apicales et latérales, on peut réaliser des greffes
Modified tunnel Double papilla flap graft gingivales libres.
technique (+ EMD/CTG) TK : tissu kératinisé ; LDC : lambeau déplacé
6 coronairement ; DMA : dérivés de la matrice
amélaire ; GTC : greffe de tissu conjonctif.

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J. M. STEIN, C. HAMMÄCHER

7a 7b

7c 7d

Fig. 7. Gingival thickening prior to orthodontic treatment. a. Pre-operative view with thin gingival biotype and initial recession (Miller class II) on the
right lower central incisor. b. Tunnelling preparation using two vertical « slot incisions » within the alveolar mucosa in order to insert the CTG. c. Post-
operative view with sutures. d. Healing result 3 months post-operative.
Fig. 7. Épaississement gingival préalable à un traitement orthodontique. a. Vue préopératoire en présence d’un biotype gingival fin et d’une récession
initiale (classe II de Miller) sur l’incisive centrale mandibulaire droite. b. Préparation à l’aide de 2 incisions verticales « en fente » réalisées dans la
muqueuse alvéolaire pour y glisser la greffe de tissu conjonctif. c. Vue postopératoire avec les sutures. d. Résultats de la cicatrisation à 3 mois postopé-
ratoires.

Besides general contraindications
for oral sur gical treatments, smo-
kers have a higher risk for impaired
wound healing, graft necrosis and
infection, which will worsen the re-
sults of root coverage with CTG (Mar-
tins et al., 2004; Chambrone et al.,
2009). Further, initial thickness of the
flap correlates with tr eatment suc-
cess (Baldi et al., 1999; Hwang and
Wang, 2009). Also, tr eatment fac-
tors such increased flap tension (Pini-
Prato et al., 2000) and surgical trau-
ma (Burkhardt et al., 2005) will limit
the gain of root coverage. Finally, it
must be emphasized that especial-
ly the modified tunnel technique is
a very technique sensitive method
that requires experience and skills
of the surgeon. Careful preparation
of the flap, in particular in patients
with thin biotype and small gingival
papillae, is essential for avoiding per-
forations. In a few cases, dissection
of extremely thin papillae may be
not possible due to the high risk of
ruptures.
As presented in figure 6, in patients
with high recession depths (> 4 mm)
and absence of keratinized tissue
apically and laterally to the r eces-
sion, a staged approach with a free
gingival graft shoul d be pr eferred

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The modified tunnel technique – options and indications for mucogingival therapy
Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

8a 8b

8c 8d

8e 8f

Fig. 8. Modified tunnel technique prior to extraction and implant insertion. a. Upper central incisors with 2 mm recessions (covered by crowns). The
right incisor is planned to be extracted. b. Replacement of both crowns by provisionals with shortened crown length. c. Coverage of both recessions
using the modified tunnel technique with two « slot incisions ». d. Healing result 2 months later. e. Healing abutment 6 months after immediate implant
insertion on the right central incisive. F. Definitive crowns on both central incisors.
Fig. 8. Technique de tunnélisation modifiée avant extraction et implantation. a. Incisives centrales maxillaires présentant des récessions de 2 mm (cou-
ronnées). L’extraction de l’incisive droite est programmée. b. Remplacement des 2 couronnes par des provisoires plus courtes. c. Recouvrement des
2 récessions à l’aide de la technique de tunnélisation avec deux incisions « en fente ». d. Résultat de la cicatrisation 2 mois plus tard. e. Pilier de cicatri-
sation 6 mois après la pose d’un implant immédiat remplaçant l’incisive centrale droite. f. Couronnes finales sur les 2 incisives centrales.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

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JPI0112_P000_000_ART_A 7/03/12 9:40 Page 11

J. M. STEIN, C. HAMMÄCHER

against tunnelling techniques. This
might, in particular, be the case if
multiple recessions in the lower jaw
are associated with a very flat ves-
tibulum.
In summary, (differential) indication
for the tunnel technique should be
done considering:
– general health and smoking ha-
bits of the patient;
– experience of the surgeon; particular multiple recessions, with
– size of the recession defects; improved integration of the graft due
– amount of surr ounding keratini- to avoidance of vertical releasing in-
zed tissue. cisions and maximal preservation of
Regarding these parameters, the blood supply.
modified tunnel technique is an in-
novative method which extends the
spectrum of plastic periodontal sur-
gery. It allows gingival augmenta-
tion in different clinical situations, in

9a 9b

9c 9d

Fig. 9. Modified tunnel technique during implant exposure in order to remain and optimize peri-implant soft tissue. a. Upper left lateral incisor prior
to extraction due to periodontal bone loss. b. Six months after implant insertion and gingival forming by an ovate pontic. c. Mobilisation of the adja-
cent papillae. d. Preparation and coronal advancement of the tunnel.
Fig. 9. Technique de tunnélisation modifiée lors de l’exposition de l’implant afin de pérenniser et d’optimiser les tissus mous péri-implantaires. a. Inci-
sive latérale maxillaire gauche avant extraction, à la suite d’une perte osseuse d’origine parodontale. b. Six mois après la pose de l’implant, remode-
lage gingival à l’aide d’un pontique ovoïde. c. Mobilisation des papilles adjacentes. d. Préparation et déplacement en direction coronaire du tunnel.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

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JPI0112_P000_000_ART_A 7/03/12 9:40 Page 12

The modified tunnel technique – options and indications for mucogingival therapy
Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

9e 9f

Fig. 9. Modified tunnel technique during implant exposure in order to remain and optimize peri-implant soft tissue. e. Insertion of the CTG. f. Healing
result and definitive crown.
Fig. 9. Technique de tunnélisation modifiée lors de l’exposition de l’implant afin de pérenniser et d’optimiser les tissus mous péri-implantaires. e. Inser-
tion de la greffe de tissu conjonctif. f. Résultat de la cicatrisation et couronne finale.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1


JPI0112_P000_000_ART_A 7/03/12 9:40 Page 13
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S e n d re p r i n t s re q u e s t s t o
Priv.-Doz. Dr. Jamal M. Stein, MSc.: Praxiszentrum für Implantologie, Parodontologie und Prothetik – Schumacherstrasse 14 –
52062 AACHEN – GERMANY – J.M.Stein@gmx.de
Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1
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